- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.64 / $14.64 / $14.64
| Professional | | $14.64 | $14.64 | $14.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.05 / $142.75 / $193.87
| Facility | | $65.05 | $142.75 | $193.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.22 / $15.22 / $204.20
| Facility | | $15.22 | $15.22 | $204.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.83 / $10.33 / $13.05
| Professional | | $5.83 | $10.33 | $13.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.22 / $15.22 / $204.20
| Facility | | $15.22 | $15.22 | $204.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.83 / $10.33 / $13.05
| Professional | | $5.83 | $10.33 | $13.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.45 / $11.72 / $29.25
| Professional | | $5.45 | $11.72 | $29.25 |